The Lev at San Antonio: Medical Records Failures - TX
A federal inspection completed August 14, 2025, found the facility was relying entirely on verbal information passed by telephone from hospital staff to its own nurses. The director of nursing confirmed this directly to inspectors. She said the facility was not requesting records from the hospital. She said a nurse, identified in the report as LVN A, had documented in the facility's electronic records system that a returning resident had no new orders, and that this information came from a phone conversation.
That was it. That was the process.
The director of nursing told inspectors she believed the facility was providing continuity of care because physicians would follow up with returning residents within a few days. She offered this as a defense of the system. What she did not explain was how a physician conducting a follow-up visit days later would know what had happened at the hospital, what treatments had been given, or what the discharge instructions had been, if no one had obtained any records.
She also told inspectors she was unsure what the facility's own policy required for obtaining and retaining hospital records.
The facility had a written policy. Inspectors reviewed it. The policy, titled Maintenance of Medical Records and dated 2023, stated the facility would maintain clinical records for each resident that were complete, accurately documented, readily accessible, and systematically organized. The director of nursing, who oversees nursing care at the facility, did not know what that policy said.
She did offer an explanation for why things had gotten to this point. She told inspectors that the industry was experiencing hospitals sending residents back to nursing facilities without any paperwork or documentation. She described this as a broader problem, not one specific to The Lev. She said the facility's response to that problem was to accept whatever verbal information the hospital provided and wait for a physician visit a few days later.
The inspection found the harm level to be minimal, or potential for actual harm, affecting a small number of residents. That classification reflects what inspectors could document. It does not capture what cannot be documented when records don't exist.
The gap this creates is not abstract. A resident returns from a hospital stay, possibly for a fall, a cardiac event, an infection. The nurse taking the phone call learns there are no new orders. The physician who will see that resident in a few days has no discharge paperwork to review. The nurse providing care in the hours and days before that visit has no written record of what the hospital found, what medications were adjusted, what follow-up was recommended. If something goes wrong in that window, the record that would explain what the hospital knew and what the facility was told does not exist.
The director of nursing said the medical records person was typically responsible for uploading any records into the computer. But if the facility is not requesting records from the hospital, there is nothing to upload.
She said she believed the facility was providing continuity of care.
The inspection report does not say whether any resident was harmed during the period when this was the facility's standard practice. It does not say how long the practice had been in place. It says the facility had a policy requiring complete and accurate records, that the director of nursing did not know what that policy required, and that when residents came back from the hospital, the facility was taking a phone call and moving on.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Lev At San Antonio from 2025-08-14 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
THE LEV AT SAN ANTONIO in SAN ANTONIO, TX was cited for violations during a health inspection on August 14, 2025.
The director of nursing confirmed this directly to inspectors.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.